PTSD at the Opioid Treatment Program

This month’s copy of the American Journal on Addictions contained an interesting article on post-traumatic stress disorder (PTSD), done with patients entering an inner-city methadone program. [1]

The purpose of the study was to determine the number of traumatic life events had been experienced by a group of patients entering a methadone program, and to determine factors which could predict the development of post-traumatic stress disorder. The study also aimed to determine the prevalence of PTSD, and whether the diagnosis of PTSD affected treatment retention at one year.

The eighty-nine study subjects of the study had a mean age of forty-three, and most were minorities, mostly black. The majority were also male, and unemployed. The categories for traumatic life experiences were described as personal trauma (serious accident or illness, financial problems, discrimination, or incarceration), familial trauma, nonsexual abuse, and sexual abuse.

Patients in this study had an average of eight traumatic life experiences, and twenty-seven percent met criteria for the diagnosis of post-traumatic stress disorder. Not surprisingly, women were four times more likely to have PTSD as men. Interestingly, those with less than a high school education were also four times more likely to have PTSD.

Two-thirds of the patients entering treatment were retained in treatment at one year, and the diagnosis of PTSD didn’t increase the likelihood of treatment drop-out. However, continued positive urine drug screens for opioids of benzos was the strongest predictor of treatment drop-out.

So what does this mean? It’s tricky to apply this data to the patients I see, who are a completely different demographic. I work at two small town methadone clinics, and the patients at both are overwhelmingly white, and reside in the small towns or in the rural countryside. Do they have fewer traumas in their lives than inner city minorities? I suspect that’s the case, but perhaps rural living brings a different kind of stress…like isolation, loneliness, or boredom.

I was particularly intrigued by the finding that less than a high school education was associated with a four-time increased risk of PTSD. In the discussion part of their study, the authors wondered if not having graduated high school was a marker for people who were cognitively impaired. These impairments could mean such people have lower resilience to stress. Or maybe people who don’t finish high school have fewer options for employment, leading to increased stress and less resilience. Some of the other studies on this topic have shown similar findings.

As in other studies, this study shows addiction and PTSD are related, but we still don’t know which comes first. Does addiction put people in dangerous situations that are likely to become traumatic? Does drug use impair judgment about how to avoid dangerous situations? Or does the PTSD cause addiction, because patients with PTSD have unpleasant feelings, and drugs provide temporary relief from unpleasant feelings?

Patients with both addiction and PTSD do better in treatment if both problems are addressed at the same time. In the past, we erred in both directions. We told patients with PTSD that if they got mental health assistance, the drug use would just go away. (That might be true if the patient with PTSD had only substance abuse and not addiction). On the other hand, in the past, some treatment providers told patients with addiction and PTSD that if they just didn’t use drugs and worked a good recovery program, everything would be fine. Clearly this isn’t true for some patients, who need specific treatment for their PTSD because their symptoms continually trigger relapse to drug use.

Ideally, all opioid treatment programs could provide on-site mental health services for patients with co-occurring mental disorders. Even better, opioid treatment programs could also provide on-site primary care for their patients, but sadly this ideal is the exception rather than the norm.

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2 responses to this post.

But Dr Burson, what exactly is the appropriate treatment for PTSD in an opioid treatment (medical-assisted) setting? I ask b/c many PTSD patients are given benzos to deal with their symptoms &/or anti-depressants. Since benzos are rarely appropriate for us, I’m not sure what would be good as a regimen. I believe I have some PTSD issues, but I have not sought a diagnosis for the symptoms that I’ve experienced. However, I can tell you that I’ve been tried on virtually EVERY anti-depressant out there (to include most of the tri-cyclics, all the atypicals, & all the SSRI’s except the newer active-isomer only drugs such as Pristique & Lexapro.) I’m still on Wellbutrin & trazodone, but none have ever helped with my PTSD-like symptoms, & I have been diagnosed as having panic/anxiety disorder over 12 years ago. I’ve been tried on Buspar, but it had unbearable side effects – severe shaking & sexual side effects as well… I was raised up way too high by one psychologist to 60mg of Prozac at one point, but after about 4 months, I had to stop it b/c of the side effects getting too far out of hand. So I’m not sure what’s left at this point to help w/such things, other than the good ol’ breathing excercises & cognitive behavior therapy (I think that’s what it’s called, right? Where you talk to yourself to calm down, breathe deeply & slowly, & maybe do some meditation if feasible, etc.) But if those things are not enough to make your heart slow down & your breathing to become normal, what can you do? I’m not particularly interested in being put on benzos, so don’t take this as some attempt to get a doc to agree with me that I need them so I can show it to my doc or something of that nature – not that doing that would make a difference in the world anyway!! But I just would like to know if there are options for treating these issues that I haven’t thought of. Thoughts on this issue? Thanks in advance for your reply.

Great question!!
Cognitive behavioral therapy, cognitive processing therapy, prolonged exposure therapy, and EMDR therapy, to name the ones with the most supportive evidence. There’s also group therapy, family therapy, and brief psychodynamic therapy.
If you want to use medication, serotonin reuptake inhibitors are first-line treatment. Many patients say these medications don’t work for them, but if I dig a little deeper, often the medication hadn’t been taken for long enough for it to work, or the dose taken high enough for it to work. These are excellent medications for anxiety disorders, but usually higher doses are needed than to treat depression.
And no medication class works for everyone. For example, if a patient with bipolar disorder also has PTSD, starting an SRI could push that patient into a manic phase, or exacerbate his anxiety.
Wellbutrin, since it raises norepinephrine levels, often makes and anxious person more anxious, unless the anxiety is actually from depression.